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The Infertility Trap

USUALLY, WHEN MASSACHUSETTS state Rep. Ronald Gauch holds monthly office hours in Shrewsbury, he hears complaints about budget cuts or potholes. But last month constituents had a more startling grievance. They told him that Massachusetts's Medicaid program was paying for welfare mothers to receive fertility drugs. At first, Gauch said, he found it "hard to believe." Then he checked state records and confirmed that Medicaid spent $46,000 last year for two drugs, Clomid and Serophene, that are prescribed only to treat infertility. Of the 260 state Medicaid patients who received the drugs last year, 58 percent were on AFDC-the Aid to Families with Dependent Children program that covers mainly single mothers-and 63 percent already had children. In fact, two of the women already had eight children each. Massachusetts's Republican Gov. William Weld abruptly banned the drugs from the state's list of Medicaid-approved medications. Democratic Sen. Edward Kennedy agreed, saying: "Our goal in using tax dollars wisely is to reduce welfare dependency, not create more of it."

At a time when Congress, President Clinton and state legislatures are pushing welfare reform, it hardly seems prudent to add more children to the rolls. But Massachusetts isn't alone. A nationwide count by NEWSWEEK revealed that 11 other states offer some form of fertility assistance through Medicaid (chart). Six other states-Maine, Wisconsin, Alabama, Connecticut, Montana and West Virginia-have ended such coverage in the last two years. The amount of money is fairly small. Nationwide, the cost of supplying the drugs and treatments is probably less than half a million dollars annually. But because the federal government pays 90 cents of every Medicaid dollar states spend on "family-planning services," U.S. tax payers fund the vast majority of fertility assistance. And the related costs run much higher. Fertility drugs increase the risk of multiple births and low-birth-weight babies, who can have extremely costly medical problems. As it is, 33 percent of all U.S. births last year were to mothers on Medicaid, and each new welfare baby fuels the cycle of public dependency, requiring more welfare payments, food stamps and other benefits.

Medicaid funding of fertility services raises philosophical questions as well: Is every woman entitled to bear a child, even if she can't afford to raise one? Can the government deny people the chance to have children, simply because they are poor? Some critics of Weld's action argued that not all Medicaid recipients are unwed welfare mothers-some are working couples who are between jobs or who just don't earn much money. "This is really welfare-bashing-it's a question of treating people equally," says Robert Restuccia of Health Care for All, a consumer group. Officials at Resolve, Inc., a Massachusetts-based infertility support group, point out that even women who already have children can have difficulty conceiving again, and they argue that infertility should be treated like any other medical problem. Dr. Alan DeCherney, president-elect of the American Fertility Society, sees civil-liberties problems in cutting off fertility aid: "We're making a decision based on a patient's socioeconomic class." On the other hand, he notes that many private insurance plans don't cover infertility services-"so why should a poor person have that benefit paid by taxpayers?"

Not surprisingly, conservative advocates of welfare reform are appalled at the idea of government subsidizing fertility aid for the poor. "It's morally irresponsible for someone to have a child and expect someone else to raise them," says Robert Rector of The Heritage Foundation. He urges the Clinton administration to remove fertility treatments from the list of optional services federal Medicaid will match, if states decide to offer them. But U.S. Medicaid director Sally Richardson says she won't press for such a move: "I think states should have the right to choose how they want to target their dollars."

Most states that cover fertility services under Medicaid aren't specifically trying to promote fertility-they've just traditionally covered most FDA-approved drugs whenever a doctor has prescribed them. But some states have concluded that the practice makes no sense. "We think that there's a real inconsistency between covering infertility drugs and trying to move recipients in the direction of more self-reliance," says Claudette Beaulieu of the Department of Social Services in Connecticut, which stopped covering fertility drugs in 1992 and will begin limiting the time state residents can stay on welfare this July. Maryland also stopped funding fertility drugs in 1992, but continues to pay for reversals of vasectomies and tubal ligations on the ground that the option encourages people to consider sterilization.

Other states are caught in what seems like a painful contradiction. New Jersey has one of the toughest welfare laws in the country; since August, mothers on welfare who have more children can no longer receive increased welfare grants. Yet New Jersey spent $233,000 on fertility assistance to Medicaid recipients last year, and intends to continue such coverage. Jacqueline Tencza of the state Department of Human Services, sees nothing peculiar about a policy that enables welfare mothers to bear more children, then denies more money to raise them. The new welfare rules, she says, are meant to promote "individual responsibility": "If a woman chooses to have a child, she knows that in New Jersey either she or the father has to take responsibility for caring for that new life. It's entirely up to them."

That rationale aside, there is now a broad political consensus that welfare recipients should be discouraged from having more children. But that bipartisan effort could end up colliding with health-care reform. Under the Clinton plan, Medicaid would no longer exist-poor people would receive the same basic benefits as other Americans. Currently, fertility treatments (except for in vitro fertilization) are included in Clinton's proposal. That would mean that all states and the federal government would have to subsidize such services-for welfare mothers and everyone else. (The administration faces the same dilemma on abortions: if they're included in the basic benefit package, then poor women can receive them, and government funds will pay for them.) Linda Bergthold, co-chair of the task force that designed the benefits package, concedes that "Congress has a discussion ahead of it on what will be guaranteed for Americans." That will include weighing the right to bear children against the desire to hold down welfare costs.